Supporting Self-care in Migrants with Type 2 Diabetes

Abstract: Background: Diabetes Mellitus, specifically type 2 diabetes, represents a growing global health concern, with a prevalence predicted to reach 783 million by 2045. Type 2 diabetes leads to personal suffering, reduced productivity and significant health care cost. Selfcare is the most important cornerstone in the treatment of type 2 diabetes and patient education is a prerequsite for performing adequate self-care. Migrants show a risk of uncontrolled diabetes and the prevalence of type 2 diabetes in migrants, living in European countries, poses challenges as cultural and language barriers might affect health care outcomes Culturally appropriate diabetes education is important for improving glycaemic control and health outcomes in migrant populations. In the Swedish health care setting, diabetes care follows national guidelines and is predominantly provided in primary health care centers. However, criticism has arisen regarding the lack of tailored care for migrants, leading to less effective health care. This thesis explores patients’ competence and health providers’ cultural competence influencing patient’s self-care.Aim: The overall aim of this thesis was to gain knowledge that can contribute to optimising support of self-care in migrants with type 2 diabetes. The aim in study I was to compare foreign‐ and Swedish‐born persons, diagnosed with type 2 diabetes, to study whether there are dissimilarities in knowledge about diabetes mellitus and to study determinants of knowledge. The aim in study II was to describe the cultural competence of primary health care professionals that specialize in diabetes care and to examine related factors that affect cultural competence. In study III the aim was to describe the process of developing a culturally appropriate tool to support self-care in migrants with type 2 diabetes and in study IV the aim was to evaluate the feasibility of a culturally appropriate website, supporting self-care in migrants with type 2 diabetes.Methods: This thesis includes four studies with two cross-sectional descriptive studies one co-design study, and one feasibility study. In study I where knowledge and glycaemic control were assessed, patients diagnosed with type 2 diabetes, receiving care at a primary health care center, participated. The data was collected with validated questionnaire and described by numbers and percentage, mean (SD) and median (range). Comparisons between groups were made by tests of statistical significance where p < 0.05 was considered statistically significant. For analytical statistics, to identify any independent associations between knowledge and socio‐demographic variables and diabetes related characteristics, multiple logistic regression analysis was performed. Data was collected between September 2014 and March 2016. Study II was also a cross-sectional study and aimed to measure perceived cultural competence in health care providers. Data was collected by a questionnaire from January to July 2020. Data was analysed by descriptive statistics and to analyse sociodemographic factors associated with the three domains, univariate analyses with bivariate correlations, independent Student t-tests, or one-way ANOVA were employed, as appropriate. Linear regression analyses were conducted, including sociodemographic factors. The third study used a co-design process, involving fourteen migrant patients, ten health care providers in diabetes care, and four researchers with data collection between February 2021 to December 2022. In the fourth study feasibility of the developed culturally appropriate website was evaluated through qualitative interviews with seven migrant patients and ten health care providers who had previously participated in study III. The interviews focused on four areas: Acceptability, Demand, Implementation, and Integration of the website. Data was analysed by directed content analysis.Result: The results show a significant gap in competence, including knowledge about diabetes and poor glycaemic control in migrants, particularly those born in the Middle East with type 2 diabetes. The thesis emphasizes the influence of cultural factors on selfcare, highlighting the need for cultural competence in health care providers working with diverse populations. A significant proportion of health care providers perceived themselves as open and aware regarding clients with other cultural backgrounds, but the health care providers perceived a lack of organizational support to improve cultural competence. In the third study, the need for a comprehensive tool providing culturally appropriate information was emphasized by both patients and health care providers. A prototype of a culturally appropriate website developed with the aim of improving the patients' competence and thereby supporting the self-care of migrants with type 2 diabetes. The website was then developed into a mobile-friendly website that patients and health care providers tested and evaluated. Both patients and health care providers experienced the website as culturally appropriate with information at a reasonably basic level, in patient's own language (Arabic) and with information provided in several different ways, such as written information, images, videos and thus accessible to those who cannot read. The participants expressed interest and demand for the website, and the planned strategy for implementation was considered reasonable. They also felt it was possible to integration the tool into existing primary health care infrastructure, as a complementary cultural appropriate tool.Conclusions: There are vulnerable groups in the society such as migrants born in the Middle East, with type 2 diabetes. This thesis highlights the importance of patient’s competence and health care providers‘ cultural competence and the influence of self-care. The development of a culturally appropriate tool, such as the website, is proposed as a practical solution to enhance patient’s competence and support health care providers in delivering culturally competent care.

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